09060044CITY OF CUPERTINO
BUILDING DIVISION PERMIT
BUILDING ADDRESS:
1 ()1'7() ,TTR MRT
PEll.MITNO.
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OWNER'S NAME: PERMIT ISSUE DATE
S'Alo¢l'rA'lty'N'O. . CONTROL NO. .
ARCHflECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
101: Z f
10 0 LICENSED CONTRACTOR'S DECLARATION
: III 1= I heroby aIJjrm thai I am licensed under provisions oC Chap.er 9 (commencing ~~ &l with Seclion 7000) DC Division 3 oCthe Business and ProCessions Code. and my license is ~~f); inCuIlCon:eandeCCeC!.
!l:l2: License Class Lic.'------------
'-0 Dale ConlraclOr.,.."...==
: ~~ ARCHITEcrS DECLARATION
! fli ::i! I understand my plans shall be osed as public rocords
I .. U 1,,__==....,......,.-.,....-------------------
: II. Ii; Licensed PmC...ional
0< OWNER-BUILDER DECLARATION ~~ I hero by ollirm thaI I am exempl Crum the COnltaClors License Law Cor the
<0 Collowing roason. (Section 7031.S. Bosiness and ProCessions Code: Any cily or coonly ~~ which requires a pennil 10 conslnlCl., aller, impmve, dcmulish. or repair any struct\lre-..,prior to its issuance. also requires me applicanl tor such permit 10 me a signed sLalCmcnl2:?< lhal he is licensed pursoanllo the provisions oC the ConltaClOr's License Law (Chapler 9:1:0 (commcncing with Section 7(00) oC Division 3 oC the Business and ProCessions C~e) or ~~ that he is exempl thereCrom and the basis Cor the allcged exemption. Any violation oC
Section 7031.5 by any applicant Cor a permit sobjeClS the applicanllo a civil penalty oC
nol moro than five hund"'d dollars ($SOO).
o I. as owner oC the property. or my employees with wages as their sole compensation.
will do the work. and thestructuro is notinlended orofTerod Corsale (Sec. 7044. Business
and ProCessions Code: The Contraclor's License Law docs not apply to an owner oC
property who boilds or improves thereon.and who docs such work himselC or through his
own employees, providcd thai soch improvements an: not inlendod orofferod Cor sale. IC.
hawever. the boilding or improvemenl is sold within one year oC complction. the owner·
builder will have the barden oC prtlving thai he did not baild or improve Cor purpose oC
sale.). .E1: as owner oC the property. am exclusively contracting with licensed conltaClors 10
""nSlJ1lClthe project (Sec. 7044. Basin ..... and ProCessions Code:) The COnltaClOr'S Li·
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Job Descripti on
DEFERRED SUBMITTAL-TRUSS CALCS, ORIG#08070099 NO
NEW PERMIT.
Sq. Ft. Floor Area Valuation
~O
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' APN Number O.ccupancy Type
32622037 . 01 r------------------=---:.--:--:---~~-------------------
cense Law does nol apply to an owner oC property who builds or improves thereon. and .
who cOnlr3.clS for such projects with a COn1taClOr(s) licensed pursuant lO lhe Contractor's
License Law. o I am exe~nder Sec. •B & PC Cor this roason
Owner --::.' ..... ~ ,
DECLARATION
I heroby affirm under penalty oC perjory one oC the Collowing declarations:
o I h..e and will maintain a Certin....oC Consent 10 seIC·;nso", CorWorter's Compen
sation. as provided Cor by Section 3700 oC the Labor Code, Cor the performance oC the
worle (or which this pennil is issued.
o I have and will maintain Worker's Compensalion Insurance. as ~uircd by Section
3700 oC the Labor Code. Cor thc performancc oC the work Cor which this permit is issocd.
My Worker's Compensation Insurance canier and Policy number an::
Canier: Policy No.: _
CERTIFICATE OF EXEMmON FROM WORKERS'
COMPENSATION INSURANCE
(This section nccd nOI be complcled iC lhe permi! is Coronc hondred dollus ($ 100)
or Ie,s.)
I certiCy th" in thc perCormanco ~ the work Cor which this ~ermil is issoed. I shall nol
employ any person in any manncr~omc sob Wo~crs' CoTpe~lion
Laws DC Cali Cornia. Dale""-. ,I~
Applicant '" b 10'"
NanCE TO APPUCANT: IC, aCler making this Certificale oC Exomplion. yoo sliould
become subjccllO the Worker's Compensation provisions of lhe Labor Code. you must
forthwith comply with such provisions or Lhis p:n:nil shall be deemed revoked.
CON!ITRUCTION LENDING AGENCY
1hereby affinn that the~ jJ a consuuetion lending agency ror the pcrfonnancc ur
lbc work Cor which Ihis permil is issoed (Scc. 3097. Civ. C.)
Lendcr's Namc -------------
Lender'sAddross _
I certify that 1 have read this application and stale that the above infonnaLiun is
correet.1 agree to comply with all city and county ort1inances and state laws relating to
building construction, and hereby IUthOri7.e representatives of this chy to cnler upon the
ahove-mentioned properly Cor inspection porposes.
(We) agn:e 10 save. indcmniCy and ltecp harmless the CilY oC Cupertino againsl
liabiliti=.judg_mcnlS. costs and expcllses which may in any way acCl'UC against said City
in conseqocnce oC the granting oC this pcrmil
APPLICANT UNDER!ITANDS AND WILL COMPLY WITIi ALL NON·POINT
SOU ~, ~2.11()5
ReqUired Inspections
DateIssued by: ~~6JJsJi!
Re-roofs C7
Type of Roof
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection. I agree to remove
all new materials for inspection.
Signature of Applicant Date
All roof coverings to be Class ':4" or better